Fig. 22.4 Enucleation in the same patient as in Fig. 22.3. (a) The prephthisical globe was removed carefully without disruption of the posterior sclera. (b) View of the socket. A simple silicone implant was placed in the irradiated socket. Photos courtesy of Dr. Bita Esmaeli

Fig. 22.5 Photograph showing the postoperative appearance in the same patient as in Fig. 22.3, after prosthesis fitting. Photo courtesy of Dr. Bita Esmaeli

22.5 Evisceration

There is considerable debate in the ophthalmic community and in the literature over the benefits of enucleation versus evisceration (removal of the contents of the eye but not the sclera) [30, 31]. The issues generally debated include the impact of surgery on implant motility and the risk of sympathetic ophthalmia. There is no question that enucleation is the appropriate choice when an eye is being removed because of an intraocular malignancy. Evisceration is not appropriate for the treatment of intraocular malignancies as this procedure may leave tumor behind. There have been instances of evisceration of eyes with previously undiagnosed intraocular malignancies [32, 33]. Before an evisceration is performed for another indication, it is extremely important to evaluate the eye to rule out the possibility of intraocular malignancy. The evaluation should include a dilated fundus examination. If the

media is not clear enough to allow for a thorough assessment via ophthalmoscopy, B-scan ultrasonography should be performed.

There are situations in which evisceration is appropriate in cancer patients without intraocular malignancy. The most frequent such situation is a blind painful eye, often due to endogenous endophthalmitis, severe viral retinitis, or severe radiation damage.

References

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21.Foster JA, Castro E, Papay FA. Reconstruction of the irradiated contracted socket with an expanded superficial temporalis fascial flap. Am J Ophthalmol 1999;127(5):621–2.

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Chapter 23

Orbital Exenteration and Rehabilitation

of the Exenterated Socket

Adam Hsu and Matthew M. Hanasono

Abstract Orbital exenteration is the surgical removal of orbital contents and periorbital structures. The majority of orbital exenterations are performed to remove malignant tumors, including primary epithelial tumors, rhabdomyosarcoma, retinoblastoma, and uveal melanoma. Other potential indications for orbital exenteration include severe and uncontrollable pain or deformity caused by extreme cases of sclerosing orbital pseudotumor, Graves’ ophthalmopathy, neurofibromatosis, and socket contracture. Generally, orbital exenteration is subclassified into three types: standard, eyelid-sparing, and extended orbital exenteration. The type of exenteration performed, as well as the planned reconstruction, depends upon the extent of the oncologic defect. The primary goal of reconstruction is to line the orbital cavity with durable tissue and to exclude the nasal and/or sinus cavities when the medial or inferior orbital wall has been removed and to protect the brain when the orbital roof has been removed. The reconstructed orbit will need to be able to tolerate radiation therapy (if planned) and to accommodate an orbital prosthesis if one is desired by the patient.

23.1 Definition

Orbital exenteration is the surgical removal of orbital contents and periorbital structures. The exact amount of surgical ablation is highly individualized based on disease involvement. Orbital exenteration may include removal of periorbital skin, adnexal soft tissue, periorbita, extraocular muscles, orbital fat, the globe, the optic nerve, one or more of the bony orbital walls, and the paranasal sinuses.

A. Hsu (B)

Section of Ophthalmology, Department of Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA

e-mail: ayhsu@yahoo.com

Oncology Series 6, DOI 10.1007/978-1-4419-0374-7_23,

C Springer Science+Business Media, LLC 2011